Proposed new NICE Guidelines 2016

The last NICE guidelines, which were indeed quite nice to osteopaths (along with acupuncturists and chiropractors), came into action around 2009/10. Now we have a draft of the revised guidelines, which should be published in September 2016.   They are only guidelines, and doctors and therapists are not bound to abide by them.  However they do indicate the way thinking is going on how to treat the complaint we see most often, and as such must be seen as hugely influential.

You can have a say until May 5th, at 5pm to be exact.

If you have any comment, it has to be done through a “stakeholder”.  I think you are best off feeding it directly to NCOR which, along with iO and the GOsC, is a stakeholder and is facilitating the feedback.  Read NCOR’s initial post on the guidelines here.    If you are the sort of person who is going to comment, you might also be the sort of person prepared to read the full draft.   I admit I have not read it and am not likely to in the near future (Easter holidays!), but I did skim the table of contents, which I always find useful in at least establishing the territory of a document, and I glanced through the first 50 pages of section 1, (on assessment and non-invasive options), and if you want to see the group of 16 people that developed these guidelines they are listed on page 11 and one of them is the BSO’s Steve Vogel, described as a manual therapist.  I think he is the only osteopath on it.

I personally found the most useful thing to look at was the 15-page short version.    It doesn’t feel like reading 15 pages: it’s mostly bullet points and you can flick through and get the gist of the recommendations fairly quickly.

If you prefer to watch and listen rather than read, watch this You Tube clip (less than 4 minutes of your life to become probably the most informed person in the room!) .  It is a concise and useful summing up by a doctor, Ian Bernstein, who was involved in the development of the guidelines.

There is also the NICE press release, which unfortunately gave  skeptics some hope, and non-physios some consternation, in referring to physiotherapists as the administrators of manual therapy.  Soon it became clear, however, that this was simply a press release term for anyone who applies manual therapy, and is not applicable to the actual guidelines which are focussing on interventions rather than the job title of whichever therapist is treating the patient.  It has already been amended to refer to “therapists” rather than physiotherapists.

So what DO these guidelines say?

A move away from interventions

OUT: belts, corsets, orthotics, rocking shoes

OUT:  acupuncture (yes, really)

OUT:  traction

OUT:  ultrasound, PENS, TENS, interferential

OUT:   paracetemol, strong opioids, antidepressants such as SSRIs and tricyclic antidepressants, anticonvulsants

OUT:  spinal injections

OUT:  spinal fusion (in most cases), disc replacement

OUT:  imaging (except sometimes in a specialist setting)

And what’s IN?

IN:  Using a tool such as the STarT Back Tool to risk assess LBP patients

IN:  Exercise – mindbody/aerobic/strengthening/relaxation, whatever type and combination suits the individual

IN:  NSAIDS (aspirin and ibuprofen), in the lowest dose for the shortest time possible, but if you cannot tolerate these you can have paracetemol alongside weak opioids

IN:  Manual therapy IS still recommended and is described as “manipulation, mobilisation or soft tissue techniques (for example, massage)” but is NOT to be used by itself; it must be used alongside exercise

IN:  Combined physical and psychological approach (preferably in a group) for persistent pain – N.B. do not use a psychological approach ALONE

IN:  Getting people back to work or back to normal daily activities

IN:  radiofrequency denervation in patients (for moderate to severe pain not improving)

IN:  epidural steroid injections for acute sciatica

IN: spinal decompression surgery for sciatica not responding to other approaches

 What’s different since last time?

  1. Not mentionning therapists by name – it’s all about interventions and not named professions
  2. I believe this document is much longer than the last
  3. Sciatica is newly included – they have called it sciatica because people know what it means, rather than ‘radiculopathy’, i.e. leg pain secondary to lumbosacral nerve root pathology.  They’re not covering cauda equina or progressive nerve deficits here because they are not non-specific low back pain and we should all know when to refer these.
  4. Acute and persistent pain are included – the guidelines used to be for pain which had lasted between 6 weeks and 12 months, which in practice did not apply to quite a lot of my patients.  Now they apply from first presentation onwards for people 16 years and over.

What are commentators saying?

The triumph of these guidelines might be that there is something for nearly everyone.  It seems that people on all sides of various debates are hailing this as some sort of victory, and as confirmation that they were right all along.

The skeptics are delighted with the omission of acupunture and the fact that osteopaths and chiropractors are no longer referred to by name; the holistic and BPS practitioners are thrilled that the focus is on multi-modal treatment tailored to the individual; the natural medicine advocates will be delighted at the move away from drug treatments; the manual therapy doubters will approve the acknowledgement that it’s not enough on its own;  the thrusters must be happy that the rarely-fully-defined word “manipulation” is still hanging on in there, and the sort of people that phone into Jeremy Vine claiming that low back pain sufferers are merely idle couch potatoes will be positively smug that their exhortations to “get on with it” and get moving are to be echoed by the health authorities.  Even persistent pain sufferers, fed up with being told that it’s all in their mind, could be mollified that psychological therapy alone is not reckoned to be effective.  You have to pity the acupuncturists though, who seem to be the only group left out in the cold.    You can see a response by the Acupuncture Association of Chartered Physiotherapists here.  Their case seems to highlight their disappointment that trials involving sham acupuncture are heavily relied upon.  I doubt that NICE respond to petitioning, but one has been set up to keep acupuncture in the NICE guidelines.

If you want to see what GPs are reading, PULSE has an excellent article summarising key recommendations and headlining with the “dramatic” reduction in drug options.

The Royal College of Chiropractic were pleased, and noted in their initial response that manipulation as specified in the guidelines is only provided by certain specialised therapists, including chiropractors and osteopaths.

Edzard Ernst was very happy with the guidelines and in his initial response read the press release to be a recommendation against osteopathy and  chiropractic (defined as “sets of modalities”) as well as acupuncture, and he really wants the published guidelines to stipulate that manual therapy can only be administerd by a physiotherapist. You can also read his comments in a Guardian article which focussed on the removal of acupuncture.  He managed to get his disapproval of manipulation in, despite it being approved in the actual guidelines.

Another one pleased with the guidelines and especially excited about the removal of acupuncture is David Colquhoun.   Read his comments here.  He was concerned that the naming of osteos, chiros and acupuncturists in the last guidelines gave us the respectability to allow bait-and-switch  (an idea that we commit something akin to retail fraud, and use the credibility bestowed by NICE to lure patients into our rooms and then taking their money in return for ineffective or downright crazy practices – I suppose he imagines us invoking power animals to cure cancer, chanting mantras to cure acne, that kind of thing ) but do have some sympathy for him.  I gather from what he writes that nothing’s cured his own back pain and he finds it hard to believe anything actually works for anyone’s low back pain.  Any positive results he regards as “regression to the mean” i.e. people go into a study when their symptoms are really bad, and any improvement is simply reflecting the fact that the pain would have got better anyway.  He regards the language of the guidelines – “Consider” manipulation, “Consider” a group exercise programme, to be NICE-speak for “It probably doesn’t work that well, but might be worth a try”.

What effect might these guidelines have?

Who knows?  I hope it might encourage the osteopathy colleges to emphasise the  psychosocial aspects of pain and teach undergraduates how to apply this understanding in clinic, if they are not already doing this.  I imagine they will also focus increasingly on exercise prescription, even some kind of coaching skills to teach us how to get unwilling patients to do exercise, or improve their body awareness in some way.

I personally never got on with acupuncture, belts, orthotics, ultrasound and the like, and left any drug prescription or referrals for things like imaging and injections  to the GPs.  So I’m relieved to know I don’t need to feel guilty for not offering them.  I might start using a risk assessment tool, and even though I’m always trying to encourage patients to exercise, I might start doing that with more vigour, or trying to find better ways to do it.

And our patients?  I personally mentionned NICE’s new recommendations on exercise to an exercise-resistant patient last week, to be met with a shrug and a wry smile.  We both knew he wasn’t going to do any.   I told another patient (a strong-minded barrister) that acupuncture has been shown to be no more effective than placebo for LBP, to be met with a pretty forceful response: “What a load of poppycock!” –   I’m paraphrasing, of course.   I doubt it will put him off something that worked for him in the past.

So these guidelines might not directly, immediately, affect individual patients, but surely there will be a trickle-down effect as the years go by.  The more interesting question now is wondering where the next guidelines will go.  Where are we heading?  These guidelines herald quite a significant shift in favour of the personalized approach osteopaths have been using for years, albeit with the manual therapy aspect less in the foreground.  They are a validation of the drug-free, gimmick-free,  appropriately tailored treatment provided by osteopaths.  Our treatment at best includes manual therapy, exercise and  lifestyle changes, along with the respect, empathy and space provided by the therapeutic relationship, which so often allows the patient to understand their body better, and to gain the confidence to make changes and self-manage their condition.  I do think, though, that our palpation and technical skills might be our USP, and it will be interesting to see where the downgrading of manual therapy (as shown in the NICE guidelines and advocated by some high profile physiotherapists) will take the various professions over the next few years.